Administration in Mental Health Vol. 8, No. 4, Summer 1981

COST-BENEFITS OF PSYCHIATRIC RESEARCH IN A GENERAL COMMUNITY HOSPITAL: Fifteen Months' Experience

Stephen Armstrong

A B S T R A C T : When viewed in the context of a general community hospital, psychiatric research is anomalous: administrators tend to fear researchers and their costs; physicians tend to see psychiatric research as diversions away from the serious business, and business it is, of service delivery. Thus, the research and its constituency is necessarily hybrid. In this article we show that Ph.D-level clinical psychologists can conduct cost-effective psychiatrie research on a quarter-time basis, that the research can address significant clinical-and-research problems, and that the research can improve clinical service delivery. The most serious factors which overload service delivery, in fact, have little to do with the researeh itself, hut, instead, reflect institutional policy, administrative shifts, or inter-institutional patterns of service delivery.

It seems to be very difficult to establish a cost/benefit ratio for mental health research. At the first level, mental health research programs require expensive personnel rather than expensive technical equipment; administrators may find it easier to raise money for a laser surgical suite than for "ano the r" mental health professional position. Second, mental heahh research methods tend to be seen as scientifically " so f t , " without an accepted set of objective treatment procedures or outcome measures (Spitzer and Klein 1976). Thus, even though researchers are in a technically better position than eren 10 years ago (Strupp and Bergin 1969), all mental heahh researchers must use and/or defend a com- p!icated, but still largely " so f t " technology in statistics, design, or measure- ment. Third, the interest of direct service clinical staff may be quite lirnited. Mental heahh clinicians typically do not carry out research, nor do they read about it; orten they seem to distrust both researchers and research findings, sometimes creating " b a d b lood" in institutions whose primary goal may be service delivery.

In support of psychiatric research, on the other hand, especially in general hospital or community settings, some state and federal laws now require that sorne tax money be spent on research activities. (Unfortunately, the statutes do not necessarily specify " g o o d " research--often " a n y research" suffices--and

Stephen Armstrong, Ph.D, is affiliated with the Department of Psychiatry, Baystate Medical Center. Reprint requests may be sent to hirn at 759 Chestnut Street, Springfield, MA 01107.

248 0090-1180/81/1400-0248500.95 ©1981 H u m a n Sciences Press

Stephen Armstrong 249

s o m e t i m e s a c o m m i t m e n t to r e sea rch ac t iv i ty m a y be h o n o r e d on ly in the

b r e a c h if the clinical e n v i r o n m e n t is ind i f fe ren t or host i le . ) Second , genera l or

c o m m u n i t y hospi ta ls are n o w a s s u m i n g respons ib i l i ty for t r ea t ing re la t ive ly

d i s t u r b e d peop le w h o f o r m e r l y were ca red for by cus todia l m e n t a l ins t i tu t ions ,

or s o m e t i m e s by the jails; t echnica l k n o w l e d g e o f h o w to t reat , or h o w to m e a -

sure o u t c o m e r e m a i n s unce r t a in . A th i rd b a l a n c i n g fac tor is tha t genera l hos-

pital p sych ia t r i c r e sea rche r s m u s t address real-life clinical conce rns , thus m a k -

ing thei r r e sea rch f indings o f g rea t e r po ten t i a l use to cl inicians.

Fo r m e n t a l hea l th a d m i n i s t r a t o r s , w h e t h e r o r no t to s u p p o r t r e sea rch in

c o m m u n i t y hospi ta l se t t ings usua l ly boils d o w n to ques t ions o f costs a n d bene-

f i t s - - c a n the r e sea rch effort co-exist wi th the need to gene ra t e r e v e n u e f r o m

clinical service de l ivery? Th i s ar t icle p resen t s di rect r evenue - se rv i ce es t imates

f r o m the expe r i ence of a P h . D . - l e v e l clinical psycho log i s t (not the au tho r ) w h o

w o r k e d for 15 consecu t ive m o n t h s wi th a 25 pe rcen t c o m m i t m e n t f r o m the gen-

eral hosp i ta l for empi r i ca l p sych ia t r i c r e sea rch . T h e resea rch w o r k did n o t add

to overal l hosp i ta l costs; it was cost-effect ive; a n d wi th in a q u a r t e r - t i m e f rame-

work , the psycho log i s t was able to w o r k on some i m p o r t a n t r e sea rch tasks tha t

he lped def ine a n d resolve ce r ta in clinical p rob l ems .

METHOD

Setting

Baystate Medical Center is the second-largest voluntary community-and-teaching hospital in Massachusetts and is currently authorized at nearly 980 beds. The Psychiatry Department oper- ates a 28-bed inpatient acute care facility ("East-1 "), the Psychiatrie Emergency Service (PES), the Psychiatrie Consultation Service (PCS), and the Outpatient Psychiatric Service (OPS). Nine psychiatrists (M.D.'s) and nine clinical psychologists (Ph.D.'s) staff the Department on a service-for-fee basis. The hospital employs all Department members as individual employees rather than as members of a practice plan. Hence, the hospital pays salaries (and bills patients) regardless of clinical service production. The hospital is incorporated as a public, nonprofit char- itable teaching hospital; it utilizes undergraduate medieal students from Tufts University Medi- tal School and graduate residents in medieine, surgery, and pediatrics.

Measures

For 15 months a research-oriented clinical psychologist worked in the OPS on his research projeets and consulted with Psychiatry Department members on their projects on a quarter-time basis. He used all other time on the OPS in direct clinical service delivery, indireet clinical activi- ties (consulting on patient eare, phone calls, follow-up care), community service (intake call rota- tion, teaching occasional lectures at local colleges), or hospital service (committee membership, consultation with other departments). His hours of direet patient care were of primary con- eern--since that is how the hospital raises money for his salary--and he was also asked about events "under his control" (endogenous variables) that affect direct service delivery: the number of patients who schedule appointments but who do not attend (' 'no shows," who cannot be billed for their defaulted hours); rated levels of "satisfaction" and "burn out" during months of ac- celerated patient care or researeh productivity; and clinical-research "tie in's" (i.e., a series of elinical experiences viewed from a research perspective). Finally, an attempt was made to assess events not under his control (exogenous variables) that also affect direct clinieal service delivery,

250 Administration in Mental Health

such as: changes in the OPS program (e.g., elimination of the group psychotherapy component, which added pressure to see more individuals); annual cyclical features (vacation, holiday season); and changes in referral patterns and external mental health programs (notably, the clos- ing of the regional state-supported mental hospital and children's school).

FINDINGS

Table 1 describes the psychologist's clinical service delivery pattern, mea- sured weekly over a 15-month period. Including those weeks when he was ill, on holiday, or on vacation; excused in order to present research findings; or attending required Department seminars, he averaged nearly 50 billable patient-hours a mon th - -o r nearly one-third time in direct patient care. He ex- ceeded the "profit point" of his service delivery in over half the weeks under study, and he exceeded the "break-even" point in about 82 percent of the weeks under study. Overall, he averaged 33 percent direct, billable hourly ser- vices per week, ranked second or third over the 73 calendar-week periods on the OPS, and, assuming a 90 percent collection rate on billables (the hospital's current collection rate), earned nearly $2,500 annually for the hospital above his gross salary and fringe benefits (computed at 25 percent of his salary).

Endogenous Factors Affecting Service Delivery

"Burn ou t" refers to a therapist 's feelings that patients or the mental health delivery system is "gett ing me down." This morale factor was a difficult one for the clinical psychologist during two 2-month periods, each stemming from an overload of difficult-to-manage patients, research papers falling due, and the grant application rejections. Each time the psychologist cut back on some research activities and "smoothed over" the rough service-delivery edges by transferring some patients (who could not tolerate intensive individual therapy) to a group psychotherapy program. A second, more chronic problem con- cerned "no-shows" ; about 10 percent of his scheduled p atients cancelled or did not come to their appointment with less than 24 hours' notice. These no-shows cost the hospital, on the average, about $300 per week in lost collections, and created pressure on the psychologist, who knew that his research efforts de- pended in part on satisfactory clinical service delivery figures.

Exogenous Factors Affecting Service Delivery

The psychologist's patient load shifted during this 15-month trial period. Nearly all patients at the start of the time span were ambulatory, nonpsychotic, unipolar depressed persons on tricyclic medications; on a relative scale of psy- chopathology, "act ing ou t " problems were minor. At the end of the 15-month period, however, about half of his patients were depressed, and the others could be grouped under the rubric of " impulsive disorders," some with multi- ple suicide attempts or homicidal or suicidal ideation, and some with addic-

&ephen Armstrong 251

Tab]e i, Part A. Monthly Effort Distribution

Month 8um of Reg. Hrs Worked

Sum of 8um of Sum of 8um of 8um of Sick Hrs Ho]i- Vacation Excused Psychiatry

day Hrs Hours Present- Seminar ins Hrs Hours

Jan 79 120 40 8 16 0 0

Feb 79 ]48 0 8 0 0 4

Mar 79 172 0 0 0 0 4

Apr 79 140 20 0 0 O 8

May 79 156 12 16 16 0 8

Jne 79 160 0 0 0 8 0

J l y 79 16 0 0 120 40 0

Aug 79 164 0 20 0 0 0

Sep 79 140 0 8 O 8 0

Oct 79 168 0 8 0 0 8

Nov 79 144 0 8 0 0 24

Dec 79 152 0 8 0 O 8

Jan 80 160 48 8 0 0 0

Feb 80 168 8 0 0 0 6

Mar 80 156 0 0 0 O 4

Mean Values + 8td Der

8um

144.2 + 37.9

2164

8.5 6.1 9.0 3.7 4.8 +15.6 +6.2 +30.9 _+10.4 +6.2

Table i, Part B. Patient Service Delivery Output

M o n t h Number of Number of Numb&r of Average ~ Average % Average % Percent of Percent of Patients Patients No-8how of Regular of Regular of Regular Weeks in Weeks in Scheduled 8een Hours in Hours Hours Hours Month Above Month Below in Month in Mon¢h Month Schedu]ed 8eeing "Wasted .... Profit "Bresk-

Per Week Patients Through Point" Eren Point" Per Week No-8hows

J a n 79 6 6 . 0 5 7 . 0 9 . 0 5 7 . 9 + 1 9 . 8

F e b 79 6 7 . 5 6 0 . 5 7 . 0 4 5 . 7 + 5 . 9

Mar 79 7 8 . 0 6 7 . 5 ] 0 . 5 4 7 . 6 + 1 1 . 6

Apr 79 62.0 56.0 6.0 35.2+23.1

May 79 68.0 60.5 7.5 43.6+16.9

Jne 79 55.5 53.5 2.0 37.5+13.9

Jly 79 0 0 0 0

Aug 79 57.0 51.0 6.0 34.9+ 7.0

Sep 79 49.5 46.0 3,5 35.0+ 5.8

Oct 79 47.0 39.5 7.5 27.2+ 7.4

Nov 79 50.0 47.0 3.0 36.5+17.5

Dec 79 76.5 63.0 13.5 42.9+24.5

Jan 80 50.0 44.0 6.0 39.0+31.3

Feb 80 55.0 49.0 6.0 27.5+15,6

Mar 80, 61.5 53.0 8.5 39.4+ 3.3

49.7+11.4 10.8+12.6 100' 0

40.3+12.9 13.0+22.8 80 20

41.5+11.6 12,8+ 9.5 100 0

31.9!21.3 18,0+11.4 60 40

38.4+ 9.6 I].3+ 9.6 80 0

36.5+13.4 2.2+ 4.9 60 20

0 0 0 1 0 0

3 1 . 6 + 7 . 4 9 . 3 ! 8 . 7 40 0

32.5+ 8.1 8.0+10,5 75 0

22.8+ 5.4 14.7+11.5 0 60

34.9+18.1 5.4+ 5.4 40 0

35.3+20.2 14.1+ 8.0 80 20

34.0B26.8 9.6 ! 9.4 60 20

24.5+14.1 8.6+ 8.9 40 20

34.0 ! 6.3 14.1+ 9.1 50 0

Mean Values 56.2 + Standard +18.2 Beviation --

8um

49.8 6.4 36.6+12.7 !15.7 ~3,4

7 4 7

32.5+11.1

34.5

9 . 6 ! 4 . 3 5 7 . 7 ! 3 0 . 5 18.7+26.7

252 Administration in Mental Health

t ions s u p e r i m p o s e d over o ther m a j o r psychia t r ic illnesses. T h e shift in pa t ien t

load followed two leads: first, the psychologis t ' s research interests in a set of

posit ive prognos t ic indicators for the m o r e d i s tu rbed impulse disorders , and ,

second, a change in referra l pa t t e rns f rom hospi tal physic ians toward the m o r e

d i s tu rbed group. M o r e o v e r , the O P S " i n t a k e " or " s c r e e n i n g " funct ion was

divided a m o n g five clinicians, r a the r t han be ing vested in one, the reby broad-

en ing the s p e c t r u m of pa t ien ts accepted for t r e a t m e n t in the O P S as a whole.

Research Costs

Direct costs inc luded t ravel and c o m p u t e r expenses over 15 mon ths (approx-

imate ly $2,500) and the billings foregone by the psychologis t ' s 25 percen t re-

search c o m m i t m e n t . T h e r e were no he igh tened indirect costs (the secretarial

and psych ia t r i c -medica l back -up would have been in place anyway , regardless

of the research c o m m i t m e n t ) . T h e psychologis t ' s billings c o m p e n s a t e for these

costs, and the hospi ta l thus did not incur any out -of -pocket expenses .

Research Benefits

T h e psychologis t used his research t ime to work on two p rob l ems that af-

fected the D e p a r t m e n t as a whole:

Example 1. During the summer of 1978, the East-1 professional staffbecame angry at the PES staff because a number of inpatients wbo had entered the hospital via the PES had voluntarily "signed out" of the inpatient division "against medical advice" (AMA), which presented legal, clinical, and professional problems to the inpatient staff. These concerns (and the blaming of the PES staff) led to an AMA follow-back study indicating that AMA patients were equally likely to come from any of four entry portals in the system--not just PES--and that AMA patients tended to leave early because of personality factors that East- 1 staff did not take into account. As a result of this study, the PES staff "tightened up" their pre-admission instructions to patients, and the East-1 staff looked more carefully at their clinical management of AMA-prone patients. The AMA rate was lowered within two months, and the hospital saved nearly 100 patient-day fees in the next quarter.

Example 2. Throughout 1979 the PES professional staff found itself having to assess a number of potentially dangerous patients--people who were destructive, suicidal, angry, or belligerent. The staff requested some research advice that could help them "get their bearings" on these pa- tients--e.g., objective measures of impulsivity or dangerousness, a "standard expectation" of the numbers of impulsive patients on any given shift (which helped PES workers not to feel over- whelmed on their own shift), and a PES emergency room psychiatric profile. A follow-up research project indicated that about 20 percent of all PES emergency patients did have problems with impulsivity at the time of evaluation, but that only a tiny minority were, in fact, dangerous. These research findings bolstered morale on the PES staff, and the study offered a number of suggestions on how to manage difficult patients during crisis evaluations.

T h e psychologis t also conduc ted his own research projects on the diagnosis and t r e a t m e n t of impuls ive pat ients , and m a d e subs tant ia l progress t oward comple- t ion of a r nonograph on the t r e a t m e n t of un ipo la r depress ion. T h e Pediatr ics D e p a r t m e n t also had two projects r eady for da ta analysis , which he comple ted

in the t ime per iod of the s tudy.

Stephen Armstrong 253

COMMENT

Mental health research by a clinician in a community hospital setting is somewhat awkward, both because of its hybrid nature, and because the re- searcher must develop dual sets of skills and professional relationships. Cur- rently, private foundations and N I M H do not support researcher-clinicians in general hospital psychiatric settings unless the hospital is a major teaching hos- pital. At current rates of reimbursement and salaries, and assuming that each professional position pays its own way, a general hospital can support research efforts from psychologists at about 25 percent time. However, the hospital may be more reluctant to support research by psychiatrists (who earn about 1.9 times a psychologist's salary at comparable levels of experience), unless he or she can get external support through a transfer of funds (from excess earnings in another position, or from the hospital's general funds).

The evidence from the 15-month research-and-clinical service experience presented here indicates that clinical psychologists can maintain cost-effective service performance in both areas. (The major threats to service delivery seem to arise, not from the research itself, but instead, from exogenous, system- wide, or extra-system factors--shifts in staffing, program development, within- hospital referrals, and other mental health programs in the area which may treat (or not treat) certain kinds ofpatients.) However, i f the psychiatric leader- ship at the hospital does not support joint clinical-research efforts, then it is doubtful whether any conceivable cost/benefit data will bolster mental health research in that hospital. There now exist a number of excellent clinical and re- search tools; in order for mental health service delivery to be improved, psy- chiatric leadership must help administrators at community hospitals under- stand the system-wide medica l - -and cost--benefits of their excellent research opportunities.

REFERENCES

Spitzer, R.L., and Klein, D.F. (Eds.), Evaluation of Psychological Therapies: Psychotherapies, Behavior Therapz?s, Drug Therapies, and Their Interactions, Baltimore: TheJohns Hopkins Press, 1976.

Strupp, H.H., and Bergin, A.E. Some empirical and conceptual bases for coordinated researeh in psycho- therapy: A critical review of issues, trends, and evidence. International]ournal of Psychiatry, 7:18-90, 1969•